لایب سان

DEFINITION OF MARRIAGE AND FAMILY THERAPY Family therapy is distinguished from other psychotherapies by its conceptual focus on the family system as a whole. In this view, ma- jor emphasis is placed on understanding how the system as a whole remains functional and on understanding individual behavior pat- terns as arising from, and inevitably feeding back into, the complex interactions within the family system. In other words, a person’s thoughts, feelings, and behaviors are seen as multidetermined and partly a product of significant interpersonal relationships. From the family systems perspective, alterations in the larger marital and family unit may therefore have positive consequences for the indi- vidual members as well as for the larger system. A major emphasis is generally placed on understanding and intervening in the family system’s current patterns of interaction, with usually only a second- ary interest in the origins and development of these interactions (de- pending on the model)

CONTENTS Introduction to the Concise Guides Series . . . . . . . . . . . . . . . . . . . . . . . . . xix Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi 1 Development of the Field and Definitions . . . .1 Definition of Marriage and Family Therapy. . . . . . . . . . . . . 1 Core Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 General Systems Theory . . . . . . . . . . . . . . . . . . . . . . . . . 2 Family Systems Theory and Homeostasis Over Time . . 6 An Integrative Interpersonal Model . . . . . . . . . . . . . . . . 7 Differentiation of Family Therapy from Other Psychotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 2 The Functional Family . . . . . . . . . . . . . . . . . . .11 The Family as a System . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 The Marital/Family Life Cycle . . . . . . . . . . . . . . . . . . . . . . 12 The Individual Life Cycle . . . . . . . . . . . . . . . . . . . . . . . 13 Phase of Relationship and Task. . . . . . . . . . . . . . . . . . . 16 Family Tasks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Provision of Basic Physical Needs . . . . . . . . . . . . . . . . 23 Rearing and Socialization of Children . . . . . . . . . . . . . 23 Use of Age-Appropriate Child-Rearing Techniques . . . 23 Maintenance of Parental Coalition and Generational Boundaries. . . . . . . . . . . . . . . . . . . . . . . 24 Support of a Sibling Coalition. . . . . . . . . . . . . . . . . . . . 24 Alternative Family Forms . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Serial Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Cohabiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Marital Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Divorce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 The Functional Single-Parent Family . . . . . . . . . . . . . . 29 Father-Headed Single-Parent Families . . . . . . . . . . . . . 30 Binuclear Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Remarriage and the Remarried Family (Stepfamilies). . 32 Grandparent-Headed Families . . . . . . . . . . . . . . . . . . . . 33 Gay and Lesbian Families . . . . . . . . . . . . . . . . . . . . . . . 34 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 3 Dysfunctional Families . . . . . . . . . . . . . . . . . .37 Current Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Structural Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 The Solution as the Problem . . . . . . . . . . . . . . . . . . . . . . . . 40 Family Beliefs and Myths . . . . . . . . . . . . . . . . . . . . . . . . . . 41 The Larger Social System and Dysfunction . . . . . . . . . . . . 42 Commentary: The Development of Symptoms in a Particular Person . . . . . . . . . . . . . . . . . . . 44 Life Cycle Problems and Dysfunction . . . . . . . . . . . . . . . . 46 Unresolved Grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Toxic Secrets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Task Performance in the Dysfunctional Family . . . . . . . . . 48 Supporting Physical Needs of Members . . . . . . . . . . . . 48 Issues of Sex, Intimacy, and Commitment: Maintaining a Functional Marriage . . . . . . . . . . . . . . . 49 Rearing and Socialization of Children . . . . . . . . . . . . . . 49 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 4 Conducting a Family Evaluation. . . . . . . . . . .53 Role of Historical Material . . . . . . . . . . . . . . . . . . . . . . . . . 53 Whom to Include in the Family Evaluation . . . . . . . . . . . . 55 Progression of the Family Evaluation Interview . . . . . . . . 57 Role of Individual and Family Diagnosis . . . . . . . . . . . . . . 59 Dimensions of Family Function . . . . . . . . . . . . . . . . . . . . . 60 Outline for Family Evaluation . . . . . . . . . . . . . . . . . . . . . . 60 Current Phase of Family Life Cycle . . . . . . . . . . . . . . . . . . 61 Identifying Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Explicit Interview Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 What Is the Current Family Problem?. . . . . . . . . . . . . . 62 Why Does the Family Come for Treatment at the Present Time? . . . . . . . . . . . . . . . . . 63 What Is the Background of the Family Problem? . . . . . 64 What Is the History of Past Treatment Attempts or Other Attempts at Problem Solving in the Family? . . 68 What Are the Family’s Goals and Expectations of the Treatment and Their Motivations and Resistances? . . 69 The Family Genogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 5 Formulating an Understanding of the Family Problem Areas . . . . . . . . . . . . . . . . . . .75 Rating Important Dimensions of Family Functioning . . . . 75 Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Problem Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Roles and Coalitions . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Affective Responsiveness and Involvement . . . . . . . . . 77 Behavior Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Operative Family Beliefs and Stories . . . . . . . . . . . . . . 78 Recent Family Events and Stresses . . . . . . . . . . . . . . . . 79 Family Classification and Diagnosis . . . . . . . . . . . . . . . . . 79 Planning the Therapeutic Approach and Establishing the Treatment Contract . . . . . . . . . . . . . . . . 85 Medical Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Home Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Family Tasks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 6 Goals in Family Treatment . . . . . . . . . . . . . . .93 Mediating and Final Goals as They Relate to Schools . . . . 93 Individualizing Goals With the Family . . . . . . . . . . . . . . . . 93 Goals and Their Relation to Process and Content Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Mediating Goals and Their Related Strategies . . . . . . . . . . 99 7 Family Treatment: Strategies and Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . .101 General Elements of Psychotherapy and Their Relationship to Family Therapy . . . . . . . . . . . . . . 102 Basic Strategies of Family Intervention . . . . . . . . . . . . . . 103 Techniques for Supporting Adaptive Mechanisms . . . 104 Techniques for Expanding Emotional Experience. . . . 106 Techniques for Developing Interpersonal Skills . . . . . 108 Strategies and Techniques for Changing Structured Family Behaviors . . . . . . . . . . . . . . . . . . . 112 Techniques for Insight and Conflict Resolution . . . . . 115 Techniques for Finding New and More Positive Ways of Understanding the Family’s Situation: The Narrative Approach . . . . . . . . . . . . . . . . . . . . . . 121 Treatment Packages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Indications for Differential Use of the Basic Strategies . . 122 Beyond Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 8 The Course of Family Therapy . . . . . . . . . . .127 Strategies for Getting Started . . . . . . . . . . . . . . . . . . . . . . 127 Distribution of Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Building a Treatment Alliance . . . . . . . . . . . . . . . . . . . . . 128 Special Issues in Evaluation . . . . . . . . . . . . . . . . . . . . . . . 132 Sexuality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Money . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Individual Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Phase of the Family Life Cycle . . . . . . . . . . . . . . . . . . 133 Evaluation Versus Treatment . . . . . . . . . . . . . . . . . . . . . . 134 Early Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Middle Phase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Termination Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 9 Promoting Change in Family Treatment: Issues of Alliance and Resistance . . . . . . . .141 The Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . 141 Models for Dealing With Families Who Have Trouble Forming an Alliance . . . . . . . . . . . . . . . . 144 The Medical Model . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 The Coaching Model . . . . . . . . . . . . . . . . . . . . . . . . . . 144 The Conflict Model . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 The Strategic Systems Model . . . . . . . . . . . . . . . . . . . 145 Difficulties in Creating Change: Disconnection and Resistance . . . . . . . . . . . . . . . . . . . . 146 Problems in Change: Within the System. . . . . . . . . . . 146 Problems in Change: Therapist Induced . . . . . . . . . . . 147 Problems in Change: Stemming From the Relationship Between Therapist and System . . . . . . 148 Problems in Change: By Phase of Treatment at Evaluation and Early in Treatment . . . . . . . . . . . . . . 149 Problems in Change: By Phase of Treatment in Ongoing Treatment . . . . . . . . . . . . . . . 152 Resistance by Phase: At the Ending Stages of Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Family Secrets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 10 Family Treatment: General Considerations. . . . . . . . . . . . . . . . .159 Family Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Time, Scheduling, and Fees. . . . . . . . . . . . . . . . . . . . . . . . 161 Keeping a Record of Treatment . . . . . . . . . . . . . . . . . . . . 162 Family Therapy in Combination With Other Psychosocial Therapies. . . . . . . . . . . . . . . . . . . . . 163 Family Therapy in Combination With Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Practical Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 The Medication Alliance . . . . . . . . . . . . . . . . . . . . . . . 168 Family Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 11 Dysfunctional Couples and Couples Therapy. . . . . . . . . . . . . . . . . . .171 Marital Difficulties, Problems, and Dysfunction . . . . . . . 171 Dynamic Point of View . . . . . . . . . . . . . . . . . . . . . . . . 172 Behavioral Point of View. . . . . . . . . . . . . . . . . . . . . . . 173 Systems Point of View . . . . . . . . . . . . . . . . . . . . . . . . . 173 Psychiatric Illness Point of View . . . . . . . . . . . . . . . . . 174 Couples/Marital Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . 174 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 The Issue of Commitment—The Problem of Affairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Evaluation of Partners . . . . . . . . . . . . . . . . . . . . . . . . . 176 Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Strategies and Techniques of Intervention. . . . . . . . . . 179 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 12 Marital and Sex Therapy . . . . . . . . . . . . . . . .185 Diagnosis: Systems Issues . . . . . . . . . . . . . . . . . . . . . . . . . 185 Some Parameters of Sexual Function . . . . . . . . . . . . . . . . 186 Assessment of Sexual Disorder . . . . . . . . . . . . . . . . . . . . 188 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Other Issues Related to Sexuality and Marriage. . . . . . . . 193 Homosexuality and Bisexuality. . . . . . . . . . . . . . . . . . 193 Marital Issues in Homosexual or Bisexual Individuals . . . . . . . . . . . . . . . . . . . . . . . . . 194 Sexual Functioning After Abuse and Rape . . . . . . . . . 194 Sexual Problems After Medical Illness . . . . . . . . . . . . 195 Sexual Problems in Elderly People . . . . . . . . . . . . . . . 196 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 13 Separation and Divorce . . . . . . . . . . . . . . . . .199 Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Separation Leading to Divorce . . . . . . . . . . . . . . . . . . . . . 200 Communicating the Issue of Divorce to Children. . . . 202 Immediate Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Therapy for Families Facing Divorce . . . . . . . . . . . . . 205 Divorce, Single-Parent and Binuclear Families, Stepfamilies, and Cohabiting Couples . . . . . . . . . . . . . . 206 Single-Parent and Binuclear Families . . . . . . . . . . . . . 207 Stepfamilies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Cohabiting Couples . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 14 Indications and Contraindications for Family Therapy. . . . . . . . . . . . . . . . . . . . . . . .215 Marital Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Marital Conflict and Dissatisfaction . . . . . . . . . . . . . . 215 Sexual Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Families in the Process of Divorce . . . . . . . . . . . . . . . 217 The Child as the Identified Patient . . . . . . . . . . . . . . . . . . 217 The Adolescent as the Identified Patient . . . . . . . . . . . . . 218 Other Intimate Interpersonal Systems. . . . . . . . . . . . . . . . 218 Couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 Family-of-Origin Issues. . . . . . . . . . . . . . . . . . . . . . . . 219 Situations in Which Family Therapy Is Difficult and Perhaps Contraindicated . . . . . . . . . . . . . . 219 Psychopathology in One Family Member Makes Family Therapy Ineffective . . . . . . . . . . . . . . 219 Family or Therapist Believes the Risks of Therapy Would Outweigh the Advantages . . . . . . . . . . . . . . . 220 Skills and Attributes of the Therapist as They Affect Family Work. . . . . . . . . . . . . . . . . . . . . . . . 222 Clinical Implications of Data From Family Therapy Outcome Studies . . . . . . . . . . . . . . . . . 222 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 15 Ethical and Professional Issues in Family Therapy . . . . . . . . . . . . . . .227 Ethical Issues Inherent in Family Therapy . . . . . . . . . . . . 227 Conflicting Interests of Family Members . . . . . . . . . . 228 Secrets and Confidentiality . . . . . . . . . . . . . . . . . . . . . 229 Ethics in a Managed Care World. . . . . . . . . . . . . . . . . . . . 232 Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 Financial Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Professional Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Boundaries and Dual Relationships . . . . . . . . . . . . . . . 234 Coding and Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 Training and Licensure . . . . . . . . . . . . . . . . . . . . . . . . 235 Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Final Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .239

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